GW1-2021-01901_Well Construction - GW1_20210429

v ELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Mark E. Holland 14•WATER ZONES I
FROM TO DESCRIPTION
Well Contractor Name a fL -2 9,fL
2178 -A ��,� �,� b ft. 8 '
NC Well Contractor Certification Number �,0 OUTER CASING for'multi-caud.welb UR.LINER'ita bk
9 )PROM TO DIAMETER 77IIC(QVESSI MATERIAL
Dennis Holland Well Drilling, Inc. g h. I ft. in.
Company Name \ 16.INNER CASING OR 1 UBING' wthernial closed-loop)
2 1 },ti���s� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit M i�'?) al ��(�`"�� o fL i Lf 3 fL in. J�
List all applicable well permits(i.e.County,State,Variance,in won,etc.)
it. ft.
3.Well Use(check well use): .17.SCREEN
Water Supply Well: FROM TO DIAMETER'. SLOT SIZE THICKNESS MATERIAL
ft. ft.
❑Agricultural u lic
❑Geothermal(Heating/Cooling Supply) es❑Muniidential Water Supply(single) ft. ft. in.
❑lndustrialICommercial ❑Residential Water Supply(shared) 18.GROUT-
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation_ ft. ft
Non-Water Supply Well:
❑Monitoring ❑Recovery tL �� ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if spoticablO
FROM TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test OStormwater Drainage
fL it j
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach addition'al'abeets:if
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,tuirdness,soiltrock tM.grain size etc
❑Geothermal(Heating/.Cooling Return) ❑Other(explain under#21 Remarks) fL fe j
ft, ft.
4.Date Well(s)Completed: �-aa � Well ID#
ft. ft.
Sa.Well Location: ��`` , ft. ft
&& F—,JA ft. ft.
Facility/O(w��ner Name Facility ID#(if applicable)
�7- T(1DD''w',, lei n.� �j
L(C e ft. ft.
_ ft. ft.
Physical Address,City,and Zipi 21.REMARKS
1,6_7 S56936 6
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.CeUofCertified
(if well field,one iat/long is sufficient) Q /
5" f fit l 7,b78 N 3`,Rla' l /+ 94* W t
i ature Well Cbnbiictor I Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or allo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also'attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. �t SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: V (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3 00'annd/2�@100') construction to the following:
( V 10.Static water level below top of casing: •/ (ft,) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:
611
(in.)
24b.For Infection Wells ONLY:I Iri addition to sending the form to the address in
Rota 24a above, also submit a copy of,this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,iUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cienter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air lift 24c.For Water Supply&Injection Wells:
lJ
Also submit one copy of this form wwithin 30 days of completion of
136.Disinfection type: H & H Amount 12 OZ. well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
I l

Macon County NEW WELL CONSTRUCTION
Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINIGNG WATER WELL
Robert Elliott 030921-P • 033223t--S
Sin le-Famil Well Residential • -------- 8.50
Off Bradie Creek Road
28 N to R on Oak Grove Church Rd.,to R on Bradley Creek Rd., R at the switchback at JW Mitchell Farms take I middle
road,site on R. l
r►ifCondidw-i:
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
Well.shall not be subject to vehicular traffic. l�/���h AC,
Well Well to maintain at least 100'minimum from all parts of the septic system. 6
Any questions call MCPH.
Diagram (Not to Scale)
! i
i C
1 v � Rows of Chestnut Trees
' ! P
150'
10'1 25%Red.Repair Area 10,
! ! - -- _ _. — _ ._ s — Min
m i
10,
j Min
12,
Text Box 10, t
160' 5'Min Min
Proposed Deck
�00'Min
_- Proposed 3 BR
Proposed Driveway
---------------------------------------------- ---
Well Area 200' ; 25'Min
50' ; 228' 1 30'
Power Poles PL/Fence/Treeline
peftltit is valid for a period of five years except that it may be revoked at any time if it is determined that there has been a material change In any fact or
nstance upon which the permit Is issued. Well location,installation,and protection must meet state regulations.The well shall be inspected and approved by Macon County
:Health before it is put Into use. The location of the well indicated by MCPH is to provide protection from possible sources of contamination. Flow volume(well yield)is NOT
nteed at any site by MCPH.
ELLHEAD COMPLETION INSPECTION MUST BE APPROVED BEFORE FINAL POWER IS GRANTED OR THE W IS PLACED INTO
ACE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION. QUE NS?(828 9-2490
Issue Date: 3/25/2021 Tanner Stamey,REHS 12 or/zed State Agent
t